My patient is a young adult with a sarcoma diagnosed in her liver. There is one large mass and several smaller ones. The tumor is not resectable right now, so she will need chemotherapy.
Two issues have arisen this week: one related to diagnostic imaging (radiology) and the other related to quality of life. With both issues I have faced significant roadblocks, placed by the patient's insurance company, that impede my ability to provide the care this young woman needs.
I'll start with the imaging issue. The patient's sarcoma is not one that typically arises in the liver. Also, the presence of multiple masses is more consistent with spread TO the liver, rather than the tumor arising FROM the liver. That means, if we hope to cure this young woman, we need to find the primary tumor. A CT scan of her chest, abdomen, and pelvis showed nothing. An MRI of her pelvis, to better evaluate her uterus, a place that this tumor could arise, showed nothing. Because a tumor like she has can come from anywhere in the body, I ordered a PET scan. The insurance company denied coverage.
Because, the physician reviewer told me, there is no evidence that a PET scan is useful in this disease.
Of course, the physician reviewer is not an oncologist, and therefore not a sarcoma specialist, so I'm sure he does not keep up with the latest literature about PET scans and sarcomas. But I do. A quick search of PubMed using the terms "sarcoma" and "PET" revealed 471 articles. I faxed him 4 of them yesterday. I hope that is sufficient evidence to allow me to get the test I, the treating physician, believe my patient needs in order to maximize my chance of curing her. I'll find out later today or tomorrow.
The other roadblock involves her quality of life. My patient will need a chemotherapy drug called ifosfamide to treat her tumor. This drug has a significant risk of infertility associated with it. After consultation with a reproductive endocrinologist, we decided that the best was to try to protect her fertility would be to use a drug called Lupron. Unfortunately, Lupron is expensive, so it requires prior authorization from the insurance company. I just received an email from our clinic coordinator that read, in part, "It won’t be covered if it’s for fertility reason (per her case manager)."
So... I have some choices to make. Do I lie and say the drug is being prescribed for another indication? Do I tell the truth and risk the family having to pay $750 per dose out of their own pockets? Or do I choose a different drug, one that will not work as well, and know that I am not providing optimal care for this young woman, and am increasing her risk of infertility?
All because her health insurance company wants to save a few bucks. At least they are "not for profit." Imagine the difficulties we face when the insurance company is trying to provide dividends for their investors, instead of health care for their customers.
Not Medically Necessary
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